About charting...

  1. I was reading an article about a malpractice case that made our front page here. An md was being sued. He claimed he told a nurse to do something stat. It wasn't done stat and that resulted in a bad outcome. Plus the patient claimed excuriating pain and misery the first 24 hours post op.

    The article said the nurses maticulous charting proved both the md and the patient were lying or mistaken.

    Never underestimate the power of good charting.
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  2. 19 Comments

  3. by   sbic56
    Touche'!! Thanks for that story, 3rdShiftGuy. I found it very empowering. (Also makes you realize both the patient and the doctor may someday be out to get you, so best to CYA now!!)
  4. by   sehbear
    Good post...
    Where do youo think that this will leave us with electronic note writing that I can assume will come in everywhere eventually. Computers can be hacked into and things altered. Are we leave ourselves at risk of being sued do you think?
  5. by   angelbear
    Excellent post we have been facing this lately at our facility. The nurses dont have alot of authority were I work so when we find something we are concerned about we call one of the oncall nurse managers. If it is not an emergency we will pass it on to a.m. shift and leave a note or voice mail. Most of the time nothing is done about it. Maybe a BM problem or a rash or something like that. Anyway when it doesnt get dealt with as the saying goes shYYt rolls down hill and we nurses are generally down hill. Ok so this has been my solution as one of my pts was admitted to hosp with very serious condition that I and 2 other nurses had reported repeatedly to no avail. So now when I notify NM per voice mail I chart just that "NM B.Joe notified per voice mail. Is this an effective way of CYA? Appropriate charting? What are your thoughts
  6. by   sbic56
    Geez, the thing that comes to mind when I see the voice mail being used in that manner is when I call my insurance agent and he isn't in I leave a messae on the voice mail, but there is a message on it that states "messages left on voice mail are not leagally binding. " I am not sure how this applies to the practice at your facility, but I'd check into it closer!
  7. by   angelbear
    Wouldnt my documenting that fact in the nurses notes back me up? I dont know how else I could prove that I let the appropriate people know of my concerns. This is becoming an issue in several situations and I just want to make sure I am covering myself. Thanks for your response.
  8. by   Katnip
    I'd think it would be the charting, not the voice mail that would be legally binding. So yes, I'd say charting that you made reasonable attempts to reach NM.

    I'm a new grad, so I haven't seen all the ins and outs, but all nurses I know write changes or problems they see and then put "physician notified" with the time. Some just put "physician" most write in the name.
  9. by   sbic56
    angelbear

    I'm not sure if your charting would cover you. That is the million dollar question! (Literally, perhaps!) I wouldn't take it for granted and would want the practice in writing as policy. Then you are covered and it is not just a shakey case of he said, she said.
  10. by   Katnip
    Charts are legal documents, allowable in court. Voice mail may not be, but if it's in the chart, she should be covered.
  11. by   BizNurse
    Guys, THIS is where the electronic charting falls WAY short.

    Being a Medical Fraud Investigator and Certified Medical Audit Specialist, I reviewed charts by the truck loads it seemed!

    Electronic charting is a LAWYER'S DREAM!!!

    For example, if you forget to uncheck the box that says IV Patent.. and the IV has actually been discontinued.. the lawyer can THEN say "DID YOU EVEN CHECK THIS PATIENT"... You charted that her IV was patent .. and she didn't even HAVE an IV...

    See what I mean???


    Linda/FCLS, CMAS, BS, RN
    BizNurse@satx.rr.com
  12. by   purplemania
    Do you have a risk management nurse? Ours is available to answer questions such as these in order to prevent the hospital from being sued. Utilize this resource. My personal opinion is that "the spoken word does not outlast ink".
  13. by   ceecel.dee
    Great thread!
    We've had a problem lately with voice orders. This doc has said, "that is not what I ordered", leaving the nurse to hang. Luckily, up to now, more than one nurse has heard what he has said (speaks rapidly, so quietly that it really appears to be his way of challenging our nurses about how close their attention is paid to Him-with-a-capitol-H).
    We have started just handing him an order sheet and asking him to write (atrocious legibility as well) his orders, and if we can't read them, we ask him to rewrite them himself. I also think his telephone orders should be heard by 2 RN's, but this is logistically difficult many times.
    We chart carefully on all patient's subjective comments, descriptions of how they are doing, etc. because he likes to come unglued about no BM for 3 days, poor sleep, noise in the hallway, the clock not keeping perfect time.....you get the picture. We state carefully, "patient refused enema this a.m., even after encouragement and education about why bowels can be a bit slower during hospitalization. Request for MOM or suppository not responded to by physician", or "Standing orders not signed by physician at time of admit, so will leave him a message about need for sleeper".
    I don't like "nurse defensively", but it seems indicated in a time of not just stressful workplaces, but anxiety-filled workplaces.
    Be careful out there!
  14. by   sbic56
    Geez, ceecel.dee, my sympathies are with you. What you are being forced to do isn't nursing; you are babysitting an insolent brat! What a piece of work.

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